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Renal system


Renal and ureteral disorders
Bladder and urethral disorders
Renal system pathology review



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High Yield Notes
4 pages


12 flashcards

USMLE® Step 1 style questions USMLE

1 questions

A 47-year-old male presents to the emergency department with altered mental status. According to the paramedics, the patient was found obtunded in an alley with empty beer cans at his side. While nursing staff attempt to establish an IV, the patient begins seizing. Temperature is 37.0°C (98.6°F), pulse is 101/min, respirations are 11/min, blood pressure is 152/74 mmHg, and O2 saturation is 95% on room air. On physical exam, the patient appears disheveled with tetany in the upper and lower extremities bilaterally. The abdomen is soft and nondistended. The patient’s laboratory findings are demonstrated below:  

 Laboratory Value, Serum  Result 
 Sodium   105 mEq/L 
 Potassium   4.2 mEq/L 
 Chloride   92 mEq/L 
 HCO3-  20 mEq/L 
 BUN  12 mg/dL 
 Creatinine   1.1 mg/dL 

Which of the following clinical findings is most likely to be present?   

External References


Tanner Marshall, MS

With hyponatremia, hypo- means under or low, and -natrium is latin for sodium, often written as Na plus, and -emia refers to the blood, so hyponatremia means a lower than normal concentration of sodium in the blood, generally below 135 mEq/L.

The concentration of sodium depends on both sodium and water levels in the body.

About 60% of our body weight comes from just water, and it basically sits in two places or fluid compartments—one third of it is in the extracellular fluid, meaning outside the cells, and two thirds of it is in the intracellular fluid, or inside cells.

The extracellular fluid includes the fluid in blood vessels, lymphatic vessels, and the interstitial space, which is the space between cells that is filled with proteins and carbohydrates.

Normally, the two compartments have the same osmolarity -- total solute concentration -- and that allows water to move freely between the two spaces.

But the exact composition of solutes differs quite a bit.

The most common cation in the extracellular compartment is sodium, whereas in the intracellular compartment it’s potassium and magnesium.

The most common anion in the extracellular compartment is chloride, whereas in the intracellular compartment it’s phosphate and negatively charged proteins.

Of all of these, sodium is the ion the moves back and forth across cell membranes, and subtle changes in sodium concentration tilts the osmolarity balance in one direction or another and that moves water.

This is why we say “wherever salt goes, water flows”.

That being said, hyponatremia, or low concentration of sodium in the extracellular fluid and therefore the blood, can be caused by either losing more sodium than water, or gaining more water than sodium.

Broadly speaking, hyponatremia can be divided into three categories based on water volume status.

The first is hypervolemic hyponatremia where there’s an enormous increase in total body water with a less significant increase in total body sodium.

Typically this is seen in conditions like congestive heart failure, cirrhosis, or nephrotic syndrome where a lot of fluid leaks out of the blood vessels and into the interstitial space, causing edema especially in the ankles.

Even though there’s more water overall, there’s a decrease in the effective circulating volume, the amount of blood flowing in the body.

That, though, stimulates the release of antidiuretic hormone, which retains pure water, leading to an increase in water, as well as aldosterone which retains sodium...but remember since water follows sodium, the body retains even more water, so ultimately there’s a large increase in water, but a small increase in sodium, leading to hyponatremia.

The second category is hypovolemic hyponatremia where there’s a small decrease in total body water with a large decrease in total body sodium.

This can occur in conditions like diarrhea or vomiting, where the cells lining the gastrointestinal tract actually pump sodium ions into the digestive juices, but then those ions don’t get reabsorbed because the undigested food and the digestive juices are tossed out of the body.

It can also develop in response to using certain medications like diuretics where sodium ions are pumped into the renal tubule and lost in the urine.

Another more nuanced condition is cerebral salt wasting which is when an intracranial injury like meningitis disrupts the normal sympathetic nervous system stimulation of the kidneys leading to disproportionate loss of sodium.

A third category is euvolemic hyponatremia, or normal volume hypovolemia, which is where there’s a normal body sodium with an increase in total body water, even though that’s contrary to the name.

The reason that it’s given that name is that you don’t have fluid pouring into the interstitial space, and therefore there’s no edema.

So no clinical signs of hypervolemia.

Euvolemic hyponatremia can be split into cases with dilute urine and concentrated urine.

Cases that cause dilute urine include adrenal insufficiency, and drinking too much water called polydipsia or beer which is called potomania.

Basically the body has a lot of water and the kidneys are trying to get rid of it as best they can.


Hyponatremia refers to a blood sodium level that is below the normal range, specifically below 135 mEq/L. This can cause several symptoms, including nausea, vomiting, headache, confusion, and fatigue. In severe cases, hyponatremia can lead to hyporeflexia, seizures, coma, and even death.

Common causes of hyponatremia include drinking too much water or other fluids without enough salt, use of certain diuretics, renal failure, syndrome of inappropriate antidiuretic hormone secretion (SIADH), etc.

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  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  4. "CURRENT Medical Diagnosis and Treatment 2020" McGraw-Hill Education / Medical (2019)
  5. "Clinical practice guideline on diagnosis and treatment of hyponatraemia" European Journal of Endocrinology (2014)
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